RESEARCH PAPER
Medical Science
Volume : 4 | Issue : 1 | Jan 2014 | ISSN - 2249-555X
Reversible cardiomyopathy in scorpion sting-a case
report
KEYWORDS
scorpion sting, antiscorpion serum, myocarditis, cardiomyopathy.
DR KAMAL LOCHAN BEHERA
DR SAMIR KUMAR PANDA
ASSOCIATE PROFESSOR, DEPARTMENT OF
MEDICINE, ASRAM MEDICAL COLLEGE, ELURU
ANDHRA PRADESH 534005
ASSOCIATE PROFESSOR, DEPARTMENT OF
MEDICINE, ASRAM MEDICAL COLLEGE, ELURU
ANDHRA PRADESH
DR Y AISWARYA
DR G SWARANALATHA
JUNIOR RESIDENT, DEPARTMENT OF MEDICINE,
ASRAM MEDICAL COLLEGE, ELURU, AP 534005
PROF AND HOD MEDICINE, ASRAMS, ELURU, A.P
ABSTRACT Scorpion envenomation is an important public health hazard in tropical and sub-tropical regions. Envenomation by scorpions can result in a wide range of clinical effects, including, cardio toxicity, neurotoxicity and
respiratory dysfunction. Out of 1500 scorpion species known to exist, about 30 are of medical importance. (1) Although
a variety of different scorpion species exist, majority of them produce similar cardiovascular effect. Scorpion envenoming
syndrome results in severe autonomic storm with massive release of catecholamines, increased levels of angiotenin2, and
increase in glucagon, cortisol, thyroid hormones; either suppressed insulin levels or hyperinsulinemia (insulin resistance),
hyperglycemia: increased circulating free fatty acid level. These hormonal alterations could be responsible for the pathogenesis of variety of clinical manifestation. Under these condition scorpion sting with myocardial damage, cardiovascular
disturbances, peripheral circulatory failure, respiratory and cardiac pulmonary edema, and many other clinical manifestations, result in a syndrome of fuel energy deficits and inability to use the existing metabolic substrate by vital organs causing
multisystem organ failures and death. Here we repot a case of reversible cardiomyopathy due to scorpion sting induced
myocarditis.
INTRODUCTION
Scorpion sting are common in our country, particularly in
the rural areas. Among 86 species of scorpions present in
India, Mesobuthus tumulus (Indian red scorpion) and Heterometrusswammerdami are of medical importance. Though
local symptoms including severe pain and burning sensation at the site of sting are the most common manifestations,
systemic complications can ensue. Cardiovascular manifestations are particularly prominent following stings by Indian red
scorpion. Such bites infrequently have serious clinical sequel,
including myocardial infarction, acute pulmonary edema, cardiogenic shock and even death. (2)
CASE REPORT
A 22 yr old male, was brought to emergency room with history of scorpion sting on the 2nd toe of left foot. The killed
scorpion was not available for identification. Patient presented to the emergency department 3 hrs later. He complained
of pain at the bite site, breathlessness, profuse sweating,
vomiting, and increased salivation. His vitals were pulse -137/
min, BP- 90/70mmHg and respiratory rate of 38/min. ECG
showed sinus tachycardia and nonspecific ST –T changes.
Suspecting myocarditis patient was advised 2D-ECHO. The
ECHO findings were global hypokinesia, severe left ventricular dysfunction with an ejection fraction of 25%. He was immediately started on dopamine and doubatamine infusion
and anti scorpion venom was given. Laboratory test showed
elevated SGOT,SGPT,CPK,MBPK ratio .Hb% level also increased to 18mg/dl with increase MCHC and PCV.Blood sugar found to be 240mg/dl.There is also lecocytosis with TLC
25000/cumm.Ten ml of sterile water for injection was used
for reconstitution of one vial of antiscorpion serum.Antiscorpion serum test dose was given. Patient was observed for
hypersensitivity to antiscorpion serum for 15 minutes. Three
ml of reconstituted antiscorpion serum is injected intramuscularly every 15 minute and the content in one antiscorpion
serum vial is given in an hour. Patient was assessed clinically
again after administration of one vial of antiscorpion serum.
As clinical severity was not noticed, so stopped with first vial
injection of antiscorpion serum. Drugs like atropine, cardiac
glycoside, diuretics glucocorticoids, beta-blocker ,ACE inhibitors are avoided as because these drugs of no use and may
do more harm.(3)With treatment the patient improved with in
3 days and his review 2D-ECHO showed only mild left ventricular dysfunction with an ejection fraction of about 45%.
Fig1.ECG shows feature of sinus tachycardia with nonspecific ST-T changes.
Fig2 echo show global hypokinesia
INDIAN JOURNAL OF APPLIED RESEARCH X 363
RESEARCH PAPER
fig3 echo show severe LVdysfunction
Volume : 4 | Issue : 1 | Jan 2014 | ISSN - 2249-555X
DISCUSSION
The scorpion venom is a water soluble antigenic complex
mixture of neurotoxin, cardio toxin, nephrotoxin, hemolysins,
phosphodiesterases, phospholipase, hyaluronidases, histamine and other chemicals. The venom can cause myocardial
damage by several pathogenetic mechanisms: Myocardial ischemia by coronary spasm, release of vasoactive, inflammatory and thrombogenic peptides and amine constituents (histamine, serotonin, bradykinin, leukotrienes, thromboxane),
which act on the coronary vasculature and induce coronary
artery vasospasm and facilitate platelet aggregation as well
as thrombosis. Direct cardio toxic effect of the venom causing toxic myocarditis by reduction of Na-K-ATPase and adrenergic myocarditis by releasing adrenaline and noradrenaline from neurons, ganglia and adrenals, thereby increasing
myocardial oxygen demand by direct inotropic and chronotropic effect on already compromised myocardial blood supply.(4) Anaphylactic reaction, due to release of allergenic
proteins causes anaphylactic shock leading to hypotension
with vasodilation and decreased of intravascular volume with
reduced myocardial perfusion. Scorpion venom inhibits angiotensin converting enzyme (ACE), resulting in accumulation of bradykinin, which is implicated in the development of
pulmonary edema. On basis of clinical manifestations at the
time of arrival to hospital and according to severity they are
graded in 4 grades.
Grade 1: severe excruciating local pain at the sting site radiating along with corresponding dermatomes, mild local
oedema with seating at the sting site, without systemic involvement.
Grade 2: signs and symptoms of autonomic storm characterized by acetyl choline excess or parasympathetic stimulation
and sympathetic stimulation
Grade 3: cold extremities, tachycardia, and hypotension or
hypertension with pulmonary edema (respiratory rate > 24
per minute, basal rales or crackles in lungs).
Grade 4: tachycardia, hypotension with or without pulmonary
edema with warm extremities (warm shock) (6)
Fig4 echo show mild LV dysfunction.
CONCLUSION
Cardiomyopathy due to myocarditis developing following
scorpion sting can threaten life due to left ventricular systolic dysfunction. This consequence has been attributed to
increased catecholaminergic activity or direct effect of toxin
to myocardial fibers. ECG must be performed, cardiac enzymes must be monitored and echocardiography must be
done to evaluate cardiac involvement in cases suffering from
such bites. Severe cases must be taken to the intensive care
unit in order to monitor respiratory and circulatory systems.
(5) As there was no evidence of coronary vascular, insufficiency, this was most probably due to a direct toxic effect
of the scorpion venom on the myocardium or secondary to
venom-induced catecholamine release from the adrenals or
sympathetic nerve endings.(7)
Fig5 echo show normal chambers
REFERENCE 1. Chippaux JP and Goyffon M. Epidemiology of scorpionism: a global appraisal. Acta Trop2008; 107:71-9. | 2. Mundle PM. Scorpion sting.
British Medical Journal1961; I: 1042. | 3. Mansour N. Delay and characteristics of scorpion bite management in Thsidi –Bouzid region. Arch
inst Pasteur Tunis2001; 78:25-31. | 4. Rajasekhar D and Mohan A. Clinical and echocardiographic findings in patients with myocardial toxicity due to scorpion sting.
National Medical Journal of India2004; 17:307-9. | 5. Bawaskar HS, Bawaskar PH. Management of the cardiovascular manifestations of poisoning by the Indian red
scorpion (Mesobuthus tamulus). Br Heart J 1992; 68(5):478-80. | 6. Gueron M, Yaron R. Cardiovascular manifestations of severe scorpion sting. Clinic pathologic
correlations. Chest 1970; 57(2):156-62. | 7. Poonking T. Myocarditis from scorpion sting. BMJ19631:374-76. |
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